درمان بیماران بستری برای اختلالات تغذیه ای: نتیجه در ترشحات و 3 ماه پیگیری

There have been few studies of inpatient treatment for eating disorders. Existing studies have mostly examined small samples of either anorexic or bulimic patients. The current study evaluated large samples of anorexic and bulimic inpatients at intake, discharge, and a 3-month follow-up. At discharge, patients in both groups showed substantial and statistically significant improvements on self-report measures of depression and eating disorder symptomatology. Treatment gains were largely maintained at follow-up. Correlational analyses found consistent inverse relationships between degree of change experienced during and after hospitalization. More favorable outcome during treatment was associated with less favorable outcome after treatment. Implications of these findings for the assessment and treatment of eating disorders are discussed.

While eating disorders are treated in both inpatient and outpatient settings, the great majority of psychotherapy outcome studies have been conducted with outpatients. Therefore, less is known about outcome, and predictors of outcome, among eating disordered patients who require inpatient treatment. In addition, unlike outpatient interventions, it is very difficult to study inpatient treatments using controlled designs. One reason is that investigators cannot ethically take the risk that patients requiring inpatient treatment might be randomly assigned to a suboptimal treatment. A second reason is that inpatient hospitalization is expensive and it is unlikely that most health insurance plans would cover treatment that was part of an experimental investigation. Nonetheless, in light of the psychiatric and medical severity of anorexia and bulimia nervosa, it is important to evaluate the degree of improvement experienced by patients during and after inpatient treatment. There are only a few studies that have assessed symptomatic change both during and after inpatient hospitalization. Engel and Wilfarth (1988) reported pretreatment, posttreatment, and 2-year follow-up data for 39 female inpatients who met diagnostic criteria for anorexia nervosa. The Structured Interview of Anorexia Nervosa (SIAN) revealed statistically significant improvements from pre- to posttreatment on measures of anxiety, obsessionality, depression, excessive thoughts of food, and the ideal of slimness. The total weight gain during inpatient treatment was approximately 10 kg, and patients' weights remained stable at a 2-year follow-up. In general, outcome on the SIAN subscales at follow-up did not significantly vary from those at the end of inpatient treatment (i.e., they remained stable). As for the inpatient treatment of bulimia nervosa, Williamson et al. (1989) reported on 27 bulimic women who had been treated in an inpatient setting for an average of 5 weeks. The Bulimia Test (BULIT), Eating Attitudes Test (EAT), Beck Depression Inventory (BDI), and Symptom Checklist-90 Revised were administered at pretreatment, posttreatment, and 6 months following treatment. The 6-month follow-up data were collected on 15 (55%) of the inpatients and were contrasted with data collected from a sample of 22 outpatients who were being treated at the same facility during the same period. The outpatients were assessed at the same periods as the inpatients (because the outpatient treatment lasted 15 weeks, their follow-up assessment was held 3 months following treatment). The inpatients had more severe symptoms than the outpatients at baseline. Both the in- and outpatient programs for bulimia resulted in statistically significant improvements on all measures. Inpatient treatment was associated with rapid improvement, while the outpatients showed more of a gradual improvement over the 15-week treatment period. Both treatment formats resulted in clinically significant improvements at the end of treatment and at follow-up for all dependent measures. However, the authors did note a trend toward relapse at follow-up for the inpatient group but not for the outpatient group. Gleaves, Post, Eberenz, and Davis (1993) analyzed pretreatment, posttreatment, and 1-, 2-, and 3-year follow-up data on 452 bulimia nervosa patients who were admitted over a 4-year period to an inpatient facility for women with eating disorders. Patients completed the Eating Disorder Inventory and Symptom Checklist-90 Revised at each assessment period. Fifty-five percent of the original sample responded to the first-year follow-up mailing, 65% from the second, and 44% from the third. The percentages of women who continued to meet the diagnostic criteria for bulimia nervosa across the three follow-up periods (35%, 42%, and 40%, respectively) did not differ significantly. This indicated that there was no trend toward further change in symptoms beyond what occurred within the first year after treatment. Across all follow-up periods, 39% continued to binge and purge frequently enough to meet the diagnostic criteria for bulimia nervosa, 25% of the women reported being completely abstinent from bingeing and purging, while the remainder continued to display subthreshold bulimic symptoms. Overall, the follow-up data suggested that the inpatients in this sample appeared to maintain their gains; albeit at a level that, for many, still reflected some degree of bulimic psychopathology. While the vast majority (88%) of these women had remained in some form of outpatient therapy following discharge, only 8.6% of the women required rehospitalization. It is difficult to render a global judgment about the effectiveness of inpatient treatment for eating disorders; rather such evaluations should be specific to particular phases of the recovery process. It would appear most useful to discuss separately the acute effects of hospitalization (i.e., pre–post comparisons), the short-term maintenance of treatment gains (e.g., up to 1 year following treatment), and long-term outcome. The extent to which follow-up assessments would be expected to reflect the effects of inpatient treatment depends on the length of the follow-up. While it would be appropriate to view a 6-month follow-up as a reflection of the effectiveness of a course of inpatient treatment, the same is not true of a 5- or 10-year follow-up. At longer follow-up periods, it is more likely that further treatment or maturational processes would better account for level of patient improvement. The current study focused on changes during and shortly after an inpatient hospitalization. The purpose of the present study was to build upon the existing literature in three ways. First, while past studies have examined treatment outcome in either anorexia or bulimia nervosa, the present study examined outcome in both types of patients treated over the same period at the same facility. Second, most previous studies have been based on relatively small samples (<50), whereas we report on sizable samples of anorexic (n=279) and bulimic (n=193) patients. Thus, the power of the present study to detect relationships is enhanced. Third, in addition to analyzing data on changes during hospitalization, we collected 3-month follow-up data on a subsample of patients. This short-term follow-up assessment provides information about susceptibility to relapse, which could be useful in designing aftercare programs for those discharged from inpatient hospitalization. In addition, to determine whether extent of change experienced during hospitalization has prognostic significance, we examined the relationship between changes occurring during and after inpatient treatment.